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Sphenoid sinus aspergilloma in trans-sphenoidal surgery for pituitary adenomas

  • Clinical Article - Neurosurgical Techniques
  • Published:
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Abstract

Background

Simultaneous appearance of sphenoid sinus aspergilloma and pituitary adenoma is a very rare finding.

Methods

Retrospective analysis of patients with sellar and sphenoid sinus mass lesions who underwent trans-sphenoidal surgery was performed. Demographic data, medical history, predisposing factors, clinical picture, neurological status and radiological findings were reviewed. All patients underwent a trans-sphenoidal microsurgical treatment, and acquired specimens underwent both histopathological and microbiological analysis.

Results

Sphenoid sinus aspergilloma was encountered in seven patients. Three patients had an isolated sphenoid sinus aspergilloma and four patients with pituitary macroadenoma had a sphenoid aspergilloma as an incidental finding.

Conclusions

Sphenoid sinus aspergilloma can be found during trans-sphenoidal surgery for pituitary adenomas. Sphenoid sinus extirpation followed by adenomectomy is the treatment of choice unless invasive aspergilloma is encountered requiring additional antifungal therapy.

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Conflicts of interest

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Authors and Affiliations

  1. Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia

    Tomislav Sajko, Živko Gnjidić, Nikolina Sesar & Maša Malenica

Authors
  1. Tomislav Sajko
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  2. Živko Gnjidić
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  3. Nikolina Sesar
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  4. Maša Malenica
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Corresponding author

Correspondence to Tomislav Sajko.

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Comments

This paper by Sajko et al. touches an important issue in pituitary surgery: not every space-occupying lesion (SOL) that appears to be a pituitary adenoma (PA) preoperatively turns out to be a PA postoperatively. The rate of unexpected histology in presumably endocrine inactive PA may be as high as 18 % [1]. Typically, endocrine inactive PA are tumours of an advanced age [2]. Interestingly, the patients with a suspected endocrine inactive PA who finally turned out to have an unexpected histology also seem to belong to the advanced age group [1]. Sajko et al. found aspergilloma in trans-sphenoidal surgery for presumed PA in basically 1.3 % of their total of about 1,000 cases. If one assumes a normal distribution of PA coming to trans-sphenoidal surgery at their institution, about 27 % would be endocrine inactive [2]. Since cases of intrasellar or parasellar aspergilloma are unlikely to present as endocrine active PA, it is probably safe to assume that the majority of the 13 patients with aspergilloma presented preoperatively as endocrine inactive PA. With this in mind, one may expect a 3–4 % rate of aspergilloma in all presumed endocrine inactive PA at the authors’ institution. This rate may even be higher in less developed regions. Just as the patients with endocrine inactive PA, the patients with intrasellar or parasellar aspergilloma were of an advanced age group. The authors found a preponderance for females, which was not the case for neoplastic unexpected histologies [1]. Diabetes mellitus or immunodeficiency was present in almost half of their patients with aspergilloma. Just as the authors conclude, awareness should be heightened especially in elderly female patients presenting with a SOL in the sphenoid sinus and the sellar region. The authors are not the first to report on aspergilloma in the sellar region [3], but they certainly are the first to present a systematic review of this non-neoplastic SOL mimicking PA in their own large neurosurgical patient cohort. It is of great importance to pituitary surgeons to be aware that not every SOL which preoperatively seems to be a PA is necessarily a PA and that it may not even be a neoplastic lesion. This awareness adds to the patients’ security, since some of those unexpected lesions may require alternative surgical strategies from the conventional PA surgery. This manuscript underscores the need to approach “pituitary” patients with an open mind.

Thomas Mindermann

Zurich, Switzerland

1. Mindermann T, Staub JJ, Probst A (1998) High rate of unexpected histology in presumed pituitary adenomas. Lancet 352(9138):1445

2. Mindermann T, Wilson CB (1994) Age-related and gender-related occurrence of pituitary adenomas. Clin Endocrinol 41:359–364

3. Petrick M, Honegger J, Daschner F, Feuerhake F, Zentner J (2003) Fungal granuloma of the sphenoid sinus and clivus in a patient presenting with cranial nerve III paresis: case report and review of the literature. Neurosurgery 52:958–959

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Sajko, T., Gnjidić, Ž., Sesar, N. et al. Sphenoid sinus aspergilloma in trans-sphenoidal surgery for pituitary adenomas. Acta Neurochir 157, 1345–1351 (2015). https://doi.org/10.1007/s00701-015-2485-6

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  • DOI: https://doi.org/10.1007/s00701-015-2485-6

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